Validación del Plan de Negocio diseñado mediante el Juicio de Expertos

Dopson and colleagues (2002) suggest that it is important for individual

providers of healthcare to belong to an established profession. The orthopaedic surgeons in my study appeared to take great pride in their membership of professional societies and networks such as the BOA, The Royal College of Surgeons and The British Hip Society amongst others. These types of

memberships acted as a ‘badge of honour’ and a method of differentiation and distinction. They could also be seen as a means of establishing power and retaining substantial autonomy, authority and control over decisions made within their sub-specialty group and organisation as a whole. The quote below demonstrates how one surgeon felt that he had to comply with the societies’ norms even though it went against the results of a recent RCT:

“You know you look at your peers who do, so you go to meetings, Society meetings, and they’re all talking about how they fix them and stuff like that, so you feel almost that you’ve got do what they do, to fit in with the society sometimes, but now because of the trial I’ve definitely fixed a lot less but it’s not very cool as you know, but you know people in the Society no matter what you say are going to fix it.”(INT C 218006)

The knowledge from the specialist societies appeared to be a highly privileged source of evidence which could enable the orthopaedic surgeons to resist external intervention from outside the group. When hospital management or policy-makers attempted to change orthopaedic practice, it would not be deemed as important to the surgeon because it had not originated from within their professional society. This is reflected in the quote below from a surgeon who would prefer guidelines to originate from his professional society rather

than from “random people” at NICE:

“I have looked on who was on the steering group for that particular (NICE) appraisal, and it wasn’t an overwhelming number of orthopaedic surgeons, it worries me that it’s almost imposed rather than … what I would say you should do is go and get a specialist society the BOA, to get their hip

guys, someone like me to go and look at it, rather than having the most random people, who I don’t really connect with.” (INT C 198005)

5.4.1.1 The group insider-outsider dynamic

I found many examples of a group insider-outsider dynamic in the data. For example, my observations revealed that when surgeons and managers met to review service redesign plans at site B, any reference to a procedural protocol or service design which had not been developed within site B was generally not

accepted as a valid evidence source (OBS notes site B SRD). This was an instance

of ‘not invented here syndrome’which has been observed in other areas of the

NHS and reflects the dominance of organisational culture as well as group norms (Millward et al, 2005). Within my study, it was the tendency of the individual surgeon in the hospital organisation to reject a seemingly suitable and sensible idea that had originated from a source outside the group, in favour of an

internally developed solution.

During my observations, this rejection ranged from a mild reluctance to share best practice from another Trust, to the outright refusal to even consider it as an option, often without any apparent consideration. In an orthopaedic meeting I

attended, one surgeon said, “I’m not using that” and pushed a document to the

edge of the table when he was asked to review a form from another department

(OBS notes site B SRD). However, I could not identify any concrete evidence that

the outside approach would be inferior, or that the internal approach would be superior or vice versa. This signified to me the importance of the surgeon group in being able to identify and define ‘their’ own reputable sources of evidence in ‘their’ department and hospital. As highlighted in the previous quote, the surgeon appeared to accept treatment guidelines from the BOA over and above those disseminated by NICE, because they had been developed by a group of insiders, i.e., other surgeons.

The professional organisation was also considered an effective source of

evidence to assist day-to-day decision-making for the groups of surgeons. There were many instances of guidelines and reports from professional bodies being used in decision-making and teaching in the departments. I often saw excerpts

and diagrams from these documents displayed on the walls of the orthopaedic departments and offices. It appeared that their presence was the norm when compared to outsider organisations such as NICE. This quote illustrates a

surgeon referring to BOA guidance as “simple” and useful:

“A good example, if you look at the BOA things…they were one page guidelines, how to treat open fractures, and they have, I can send you some if you remind me, but they are really useful clinically. I haven’t got any on me. There are some up in theatre. They’ve just produced a few more, but they’re simple and we can use them. So I don’t know what we need to do with NICE.” (INT C 198005)

On the whole, the norms of the professional orthopaedic networks and societies appeared to lead professionals from the same group to behave and act similarly. This was regardless of their particular specialty interest and personal incentives. When interviewing the surgeons about their process of knowledge selection, they would often refer to being influenced by discussions and presentations that took place at national conferences. These appeared to achieve a wider reach and

memorable impact on the surgeons. They often declared that they “saw

something at a conference” and then wanted to bring it back into their practice.

The consultant quoted below reflects on hearing a “brilliant” talk at a conference,

and being inspired to change practice, based on what he had heard at a presentation the day before:

“You know getting into the presentation on fractures that was presented at the Society, and it was brilliant, it was the best presentation I think I’ve ever seen. I’ve taken the view that I generally believe in the study and you know it’s the grey area.” (INT C 218006)

5.4.1.2 Trust in evidence that originates from professional groups

The findings revealed that the use of professional evidence in decision-making was likely to be complex and fraught with political challenges. Interview

participants often also discredited or approved of information from conferences due to beliefs about the particular individual presenting, or the academic group where the work originated. This issue of trust might be linked to how surgeons maintain their elite position in the wider clinical field. As described in the literature reviews, professionals privilege the normative knowledge of their group and therefore their own clinical specialty over information produced by

others in the field. For example, presentations delivered by other academic groups would be privileged over and above clinical guidelines produced by policy-makers such as NICE.

This seemed to be particularly the case if they felt that a report or guideline might have a negative impact on the discretion they exercised in their group and over their practice. Various surgeons reported concerns regarding the wider political influence from the Government on guidelines that are produced. This surgeon suggests politicians are interfering with NICE guidelines:

“So NICE has a, you know, it’s a tight rope, but it is at a whim, like the NHS is, of being interfered with by politicians. I think most doctors just hate that, don’t we really?. Like when [politicians name] said we’ll stick an extra £200 million into the cancer drug budget, you know, why should, why are they any more needy.They’re politically emotive decisions.” (INT C 198005)

In addition some sites did not trust evidence that came from implant

manufacturers, preferring more ‘impartial’ sources, for example within site A, the group norm was to conduct and promote EBM, hence this group appeared to privilege knowledge resulting from RCTs and journal articles. One example is shown below:

“Yeah, I mean I’d say in our department it’s very openly discussed but more so because we’re a clinical academic department. So there’s posters everywhere for trials that are currently happening and I suppose an example we recently completed a trial looking at distal radius fractures which is a very common simple thing that comes through clinic all the time. These patients, these particular patients need an operation and we compare two different types of operation and we found that there was no difference between them but one of the operations is a lot cheaper than the other one, so there’s a cost effectiveness element to it. So as a result of that coming through just in the last couple of months the unit’s changed practice and we no longer use the other operation. So that’s an example of how evidence does directly influence what happens within the department.” (INT C 218012)

Surgeons in site A talked about being cautious of the underlying message of

conference presentations and who was paying for, or “sponsoring” the talk. They

appeared to take a critical stance on evidence that came from elsewhere and

at (OBS notes site A gen). To me, there was an assumption that individuals at conferences would be influenced by the implant manufacturer who had paid for the attendance and presentation of particular surgeons. Orthopaedic surgeons at site A were reluctant to take sponsorship in any way as they believed it

negatively impacted on their competing interest declaration statements for journals and grant applications. This is shown in the quote below. I did not observe this at any of the other sites I visited and it demonstrates the power of this group norm at site A.

“They always have stands in the foyers always advertising the next new thing, whatever they’re doing. And they sponsor a lot of things as well, so they’ll take a group of registrars or orthopaedic consultants out for dinner and pay for drinks or … there’s a lot of wining and dining in the hope that they will then use their particular prosthesis. In some cases, because we’re quite a clinical academic department there’s obviously issues with conflict of interests so certainly all my colleagues don’t engage in those activities, just because if you do engage in them you then have to declare it on your grants and publications. It’s all a bit of a headache, all for a free dinner! Not worth it.” (INT C 218012)